genitourinary dysfunction

8/6/2019 Genitourinary Dysfunction

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NURSING MANAGEMENTNURSING MANAGEMENTOF GENITOURINARYOF GENITOURINARYDYSFUNCTION:DYSFUNCTION:

Theoretical Skills and Knowledge,Scientific Principles, Critical

Thinking, Healthcare Promotion,

Wellness and Illness, and StressAdaptation


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Lecture Objectives:Lecture Objectives:

1.1. Describe common renal and urinaryDescribe common renal and urinarydisorders that occur in children.disorders that occur in children.

2.2. Assess a child for a renal or urinary tractAssess a child for a renal or urinary tract

disorder.disorder.3.3. Formulate nursing diagnoses related toFormulate nursing diagnoses related to

renal or urinary tract disorders.renal or urinary tract disorders.

4.4. Establish outcomes related to the care ofEstablish outcomes related to the care of

a child with renal or urinary disorder.a child with renal or urinary disorder.5.5. Plan nursing care related to urinary orPlan nursing care related to urinary or

renal disorders.renal disorders.


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Lecture Objectives (cont.)Lecture Objectives (cont.)

6.6. Implement nursing care for the child with aImplement nursing care for the child with arenal or urinary disorder.renal or urinary disorder.

7.7. Evaluate outcomes for achievment andEvaluate outcomes for achievment andeffectiveness of care.effectiveness of care.

8.8. Analyze methods for making nursing care of theAnalyze methods for making nursing care of thechild with a renal or urinary disorder morechild with a renal or urinary disorder morefamily centered.family centered.

9.9. Compare and contrast acute and chronic renalCompare and contrast acute and chronic renal

failure.failure.10.10. Discuss the types of renal dialysis.Discuss the types of renal dialysis.

11.11. Assess for signs of kidney transplant rejection.Assess for signs of kidney transplant rejection.


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Reading Assignment:Reading Assignment:

Wong, Perry & Hockenberry

Ch. 50; p 1643-1669


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Renal System AssessmentRenal System Assessment Physical assessmentPhysical assessment

Palpation, percussionPalpation, percussion

Health historyHealth history

Previous UTIs, calculi, stasis,Previous UTIs, calculi, stasis,

retention, pregnancy, STDs, bladderretention, pregnancy, STDs, bladdercancercancer

Meds: antibiotics, anticholinergics,Meds: antibiotics, anticholinergics,antispasmodicsantispasmodics

Urologic instrumentationUrologic instrumentation

Urinary hygieneUrinary hygiene

Patterns of eliminationPatterns of elimination


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Nursing AssessmentNursing Assessment

of Urinary Tract Infectionof Urinary Tract Infection(UTI)(UTI)

Nausea, vomiting, anorexia,Nausea, vomiting, anorexia,

chills, nocturia, frequency,chills, nocturia, frequency,urgencyurgency

Suprapubic or lower back pain,Suprapubic or lower back pain,

bladder spasms, dysuria,bladder spasms, dysuria,burning on urinationburning on urination


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Nursing AssessmentNursing Assessmentof Urinary Tract Infectionof Urinary Tract Infection

(UTI)(UTI) Objective dataObjective data

FeverFever Hematuria, foulHematuria, foul--smelling urine; tender,smelling urine; tender,

enlarged kidneyenlarged kidney

Leukocytosis, positive findings forLeukocytosis, positive findings for

bacteria, WBCs, RBCs, pyuria,bacteria, WBCs, RBCs, pyuria,ultrasound, CT scan, IVPultrasound, CT scan, IVP


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Diagnostic StudiesDiagnostic Studies

Renal scanRenal scan

CystogramCystogram

RetrogradeRetrogradepyelogrampyelogram

UltrasoundUltrasound

CTCT

MRIMRI

Renal arteriogramRenal arteriogram

UAUA

Urine C&SUrine C&S

BUNBUN CreatinineCreatinine

KUBKUB

IVPIVPVCG/VCUGVCG/VCUG


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Normal UrinalysisNormal Urinalysis

pH: 5 to 9pH: 5 to 9 Sp gr: 1.001 to 1.035Sp gr: 1.001 to 1.035 Protein:


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Normal Characteristics of UrineNormal Characteristics of Urine

Color rangeColor range

ClearClear

Newborn productionNewborn productionapprox 1approx 1--22ml/kg/hrml/kg/hr

Child productionChild productionapprox 1 ml/kg/hrapprox 1 ml/kg/hr


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Urinary Tract Infection (UTI)Urinary Tract Infection (UTI)

Is itIs it reallyreally thatthatserious?serious?

Concept ofConcept ofasymptomaticasymptomaticbacteria in urinarybacteria in urinarytracttract


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Urinary Tract Infection (UTI)Urinary Tract Infection (UTI)

CausesCauses

Escherichia coliEscherichia coli mostmost

common pathogencommon pathogen StreptococciStreptococci

StaphylococcusStaphylococcus

saprophyticussaprophyticus Occasionally fungal andOccasionally fungal and

parasitic pathogensparasitic pathogens


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Classification of UTIClassification of UTI

Upper tract:Upper tract: involves renalinvolves renalparenchyma, pelvis, and uretersparenchyma, pelvis, and ureters

Typically causes fever, chills, flankTypically causes fever, chills, flankpainpain

Lower tract:Lower tract: involves lower urinaryinvolves lower urinarytracttract

Usually no systemic manifestationsUsually no systemic manifestations


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Lower tractLower tract

CystitisCystitis

UrethritisUrethritis GlomeruloGlomerulo--

nephritisnephritis

Upper tractUpper tract

PyelonephritisPyelonephritis

VURVUR


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Uncomplicated infectionUncomplicated infection

Complicated infectionsComplicated infections

StonesStones

ObstructionObstruction

CathetersCatheters

Diabetes or neurologicDiabetes or neurologicdiseasedisease

Recurrent infectionsRecurrent infections


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Types of UTIsTypes of UTIs

RecurrentRecurrentrepeated episodesrepeated episodes

PersistentPersistentbacteriuria despitebacteriuria despite

antibioticsantibiotics FebrileFebriletypically indicatestypically indicates

pyelonephritispyelonephritis

UrosepsisUrosepsisbacterial illness; urinarybacterial illness; urinarypathogens in bloodpathogens in blood


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Etiology andEtiology and

Pathophysiology of UTIPathophysiology of UTI Physiologic and mechanicalPhysiologic and mechanical

defense mechanisms maintaindefense mechanisms maintain

sterilitysterility Emptying bladderEmptying bladder

Normal antibacterial properties ofNormal antibacterial properties ofurine and tracturine and tract

Ureterovesical junctionUreterovesical junctioncompetencecompetence

Peristaltic activityPeristaltic activity


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Etiology and Pathophysiology ofEtiology and Pathophysiology of

UTIUTIAlteration of defenseAlteration of defense

mechanisms increases riskmechanisms increases risk

of UTIof UTI Organisms usuallyOrganisms usually

introduced via ascendingintroduced via ascendingroute from urethraroute from urethra

Less common routesLess common routes BloodstreamBloodstream

Lymphatic systemLymphatic system


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UTIUTI Contributing factor: urologicContributing factor: urologic

instrumentationinstrumentation

Allows bacteria present in opening ofAllows bacteria present in opening ofurethra to enter urethra or bladderurethra to enter urethra or bladder

Sexual intercourse promotesSexual intercourse promotesmilkingmilking

of bacteria from perineum andof bacteria from perineum andvaginavagina May cause minor urethral traumaMay cause minor urethral trauma


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UTIUTI UTIs rarely result fromUTIs rarely result from

hematogenous routehematogenous route

For kidney infection to occurFor kidney infection to occurfrom hematogenousfrom hematogenoustransmission, must have priortransmission, must have priorinjury to urinary tractinjury to urinary tract

Obstruction of ureterObstruction of ureter

Damage from stonesDamage from stones

Renal scarsRenal scars


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UTIUTI UTI is a common nosocomialUTI is a common nosocomial

infectioninfection

OftenOften E. coliE. coli

SeldomSeldom PseudomonasPseudomonas

Urologic instrumentationUrologic instrumentation

common predisposing factorcommon predisposing factor


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Clinical Manifestations of UTIClinical Manifestations of UTI

SymptomsSymptoms

DysuriaDysuria

Frequent urination (>q2h)Frequent urination (>q2h) UrgencyUrgency

Suprapubic discomfort orSuprapubic discomfort orpressurepressure


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Clinical Manifestations of UTIClinical Manifestations of UTI

Urine may contain visible blood orUrine may contain visible blood orsediment (cloudy appearance)sediment (cloudy appearance)

Flank pain, chills, and feverFlank pain, chills, and feverindicate infection of upper tractindicate infection of upper tract(pyelonephritis)(pyelonephritis)


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Pediatric ManifestationsPediatric Manifestations

FrequencyFrequency

Fever in some casesFever in some cases

Odiferous urineOdiferous urine Blood or bloodBlood or blood--tinged urinetinged urine

Sometimes NO symptomsSometimes NO symptoms

except generalized sepsisexcept generalized sepsis


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Pediatric ManifestationsPediatric Manifestations

Pediatric patients withPediatric patients withsignificant bacteriuria may havesignificant bacteriuria may haveno symptoms or nonspecificno symptoms or nonspecificsymptoms like fatigue orsymptoms like fatigue oranorexiaanorexia

So how do you find out?So how do you find out?


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Diagnostic Studies of UTIDiagnostic Studies of UTI

DipstickDipstick

MicroscopicMicroscopicurinalysisurinalysis

CultureCulture


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CleanClean--catch is preferredcatch is preferred

UU--bag for collection from childbag for collection from child

Specimen obtained bySpecimen obtained bycatheterization or suprapubiccatheterization or suprapubicneedle aspiration has moreneedle aspiration has moreaccurate resultsaccurate results

May be necessary when cleanMay be necessary when clean--catchcatchcannot be obtainedcannot be obtained


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Sensitivity testing determinesSensitivity testing determinessusceptibility to antibioticssusceptibility to antibiotics

Imaging studies for suspectedImaging studies for suspectedobstructionobstruction

IVP or Abd CTIVP or Abd CT


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Collaborative Care for UTICollaborative Care for UTI

Drug Therapy: AntibioticsDrug Therapy: Antibiotics Uncomplicated cystitis: shortUncomplicated cystitis: short--

term course of antibioticsterm course of antibiotics

Complicated UTIs: longComplicated UTIs: long--termtermtreatmenttreatment


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Drug Therapy: AntibioticsDrug Therapy: Antibiotics TrimethoprimTrimethoprim--sulfamethoxazole (TMPsulfamethoxazole (TMP--

SMX) or nitrofurantoinSMX) or nitrofurantoin

AmoxicillinAmoxicillin

CephalexinCephalexin OthersOthers

Gentamycin, carbenicillinGentamycin, carbenicillin ++++

Pyridium (OTC)Pyridium (OTC)

Combination agents (e.g., Urised) used toCombination agents (e.g., Urised) used torelieve painrelieve pain

Preparations with methylene blue tintPreparations with methylene blue tint


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Drug TherapyDrug Therapy For repeated UTIsFor repeated UTIs

Prophylactic or suppressiveProphylactic or suppressive

antibioticsantibiotics TMPTMP--SMX administered daily toSMX administered daily to

prevent recurrence or singleprevent recurrence or singledose before events likely todose before events likely to

cause UTIcause UTI


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Etiology and PathophysiologyEtiology and Pathophysiology

of Acute Pyelonephritisof Acute Pyelonephritis Inflammation caused byInflammation caused by

bacteria, fungi, protozoa, orbacteria, fungi, protozoa, or

viruses infecting kidneysviruses infecting kidneys Urosepsis: systemic infectionUrosepsis: systemic infection

from urologic sourcefrom urologic source

Can lead to septic shock and deathCan lead to septic shock and deathin 15% of casesin 15% of cases


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of Acute Pyelonephritisof Acute Pyelonephritis Usually infection isUsually infection is

via ascendingvia ascending

urethral routeurethral route Frequent causesFrequent causes

E. coliE. coli

Proteus

Proteus

KlebsiellaKlebsiella

EnterobacterEnterobacter


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of Acute Pyelonephritisof Acute Pyelonephritis Commonly starts in renalCommonly starts in renal

medulla and spreads tomedulla and spreads to

adjacent cortexadjacent cortex Recurring episodes lead toRecurring episodes lead to

scarred, poorly functioningscarred, poorly functioningkidney and chronickidney and chronicpyelonephritispyelonephritis


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Clinical ManifestationsClinical Manifestations

of Acute Pyelonephritisof Acute Pyelonephritis Vary from mild to classic and very severeVary from mild to classic and very severe

Presenting symptomsPresenting symptoms

N/V, anorexia, chills, nocturia, frequency,N/V, anorexia, chills, nocturia, frequency,urgencyurgency

Suprapubic or low back pain, dysuriaSuprapubic or low back pain, dysuria

Fever, hematuria, foulFever, hematuria, foul--smelling urinesmelling urine

Costovertebral tendernessCostovertebral tenderness

Symptoms often subside in a few days, evenSymptoms often subside in a few days, evenwithout therapywithout therapy

Bacteriuria and pyuria still persistBacteriuria and pyuria still persist


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Diagnostic StudiesDiagnostic Studies

of Acute Pyelonephritisof Acute Pyelonephritis UrinalysisUrinalysis

WBC castsWBC casts

CBCCBC Imaging studies (IVPImaging studies (IVP

or CT)or CT)

UltrasoundUltrasound


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Collaborative CareCollaborative Care

of Acute Pyelonephritisof Acute Pyelonephritis HospitalizationHospitalization

ParenteralParenteral

antibioticsantibiotics


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Collaborative CareCollaborative Care

of Acute Pyelonephritisof Acute Pyelonephritis Relapses treated with 6Relapses treated with 6--weekweek

course of antibioticscourse of antibiotics

Reinfections treated asReinfections treated asindividual episodes orindividual episodes ormanaged with longmanaged with long--termtermtherapytherapy

Prophylaxis may be used forProphylaxis may be used forrecurrent infectionsrecurrent infections


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Types of GlomerulonephritisTypes of Glomerulonephritis

Most are postinfectiousMost are postinfectious Pneumococcal, streptococcal,Pneumococcal, streptococcal,

or viralor viral

May be distinct entityMay be distinct entity oror May be a manifestation ofMay be a manifestation of

systemic disordersystemic disorder SLESLE

Sickle cell diseaseSickle cell disease OthersOthers


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GlomerulonephritisGlomerulonephritis

SymptomsSymptoms Generalized edema due toGeneralized edema due to

decreased glomerular filtrationdecreased glomerular filtration

Begins with periorbitalBegins with periorbital

Progresses to lower extremitiesProgresses to lower extremitiesand then to ascitesand then to ascites

HTN due to increased ECFHTN due to increased ECF

OliguriaOliguria


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Glomerulonephritis SymptomsGlomerulonephritis Symptoms

HematuriaHematuria

Bleeding in upper urinaryBleeding in upper urinary

tracttract

smoky urinesmoky urine ProteinuriaProteinuria

Increased amount of protein =Increased amount of protein =increased severity of renal diseaseincreased severity of renal disease


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Acute PostAcute Post--StreptococcalStreptococcal

GlomerulonephritisGlomerulonephritis Is a noninfectious renal diseaseIs a noninfectious renal disease

AutoimmuneAutoimmune

Onset 5 to 12 days afterOnset 5 to 12 days after otherother type oftype ofinfectioninfection

Often group A Often group A --hemolytic streptococcihemolytic streptococci

Most common in 6 to 7 years oldMost common in 6 to 7 years old

Uncommon in


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Diagnosing APSGDiagnosing APSG


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PrognosisPrognosis

95%95%rapid improvement torapid improvement tocomplete recoverycomplete recovery

5% to 15%5% to 15%chronicchronicglomerulonephritisglomerulonephritis

1%1%irreversible damageirreversible damage


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Nursing Management ofNursing Management of

APSGAPSG Manage edemaManage edema Daily weightsDaily weights

Accurate I&OAccurate I&O

Daily abdominal girthDaily abdominal girth

NutritionNutrition Low sodium, low toLow sodium, low to

moderate proteinmoderate protein

Susceptibility to infectionsSusceptibility to infections

Bed rest is not necessaryBed rest is not necessary


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Nephrotic SyndromeNephrotic Syndrome

Most common presentation ofMost common presentation ofglomerular injury in childrenglomerular injury in children

CharacteristicsCharacteristics ProteinuriaProteinuria

HypoalbuminemiaHypoalbuminemia

HyperlipidemiaHyperlipidemia

EdemaEdema

Massive urinary protein lossMassive urinary protein loss


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Types of NephroticTypes of Nephrotic

SyndromeSyndrome Minimal change nephrotic syndromeMinimal change nephrotic syndrome(MCNS)(MCNS)AKAAKA

Idiopathic nephrosisIdiopathic nephrosis Nil diseaseNil disease Uncomplicated nephrosisUncomplicated nephrosis Childhood nephrosisChildhood nephrosis Minimal lesion nephrosisMinimal lesion nephrosis

Congenital nephrotic syndromeCongenital nephrotic syndrome Secondary nephrotic syndromeSecondary nephrotic syndrome


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Changes in NephroticChanges in Nephrotic

SyndromeSyndrome Glomerular membraneGlomerular membrane Normally impermeable to large proteinsNormally impermeable to large proteins

Becomes permeable to proteins,Becomes permeable to proteins,especially albuminespecially albumin

Albumin lost in urineAlbumin lost in urine(hyperalbuminuria)(hyperalbuminuria)

Serum albumin decreasedSerum albumin decreased(hypoalbuminemia)(hypoalbuminemia)

Fluid shifts from plasma to interstitialFluid shifts from plasma to interstitialspacesspaces

HypovolemiaHypovolemia

AscitesAscites


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Nephrotic SyndromeNephrotic Syndrome

ManagementManagement Supportive careSupportive care DietDiet

Low to moderate proteinLow to moderate protein Sodium restrictions when largeSodium restrictions when large

amount edema presentamount edema present SteroidsSteroids

2 mg/kg divided into BID doses2 mg/kg divided into BID doses Prednisone drug of choice ($$ andPrednisone drug of choice ($$ and

safest)safest) Immunosuppressant therapyImmunosuppressant therapy(Cytoxan)(Cytoxan)

DiureticsDiuretics


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Family IssuesFamily Issues

Chronic condition with relapsesChronic condition with relapses Developmental milestonesDevelopmental milestones Social isolationSocial isolation

Lack of energyLack of energy

Immunosuppression/protectionImmunosuppression/protection Change in appearance due toChange in appearance due to

edemaedema

SelfSelf--imageimage


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Nursing InterventionsNursing Interventions

Aseptic technique duringAseptic technique duringcatheterizationscatheterizations

Avoid unnecessary catheterizationAvoid unnecessary catheterizationand early removal of indwellingand early removal of indwellingcatheterscatheters

Prevents nosocomial infectionsPrevents nosocomial infections

Wash hands before and after contactWash hands before and after contact

Wear gloves for care of urinary systemWear gloves for care of urinary system


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Routine and thorough perineal careRoutine and thorough perineal carefor all hospitalized patientsfor all hospitalized patients

Avoid incontinent episodes byAvoid incontinent episodes byanswering call light and offeringanswering call light and offeringbedpan at frequent intervalsbedpan at frequent intervals


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Ensure adequate fluid intakeEnsure adequate fluid intake(patient with urinary problems may(patient with urinary problems maythink will be more uncomfortable)think will be more uncomfortable)

Dilutes urine, making bladder lessDilutes urine, making bladder lessirritableirritable

Flushes out bacteria before they canFlushes out bacteria before they can

colonizecolonizeAvoid caffeine, alcohol, citrus juices,Avoid caffeine, alcohol, citrus juices,

chocolate, and highly spiced foodschocolate, and highly spiced foods

Potential bladder irritantsPotential bladder irritants


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Discharge to home instructionsDischarge to home instructions

FollowFollow--up urine cultureup urine culture Recurrent symptoms typically occur in 1 to 2Recurrent symptoms typically occur in 1 to 2

weeks after therapyweeks after therapy

Encourage adequate fluids even afterEncourage adequate fluids even afterinfectioninfection

LowLow--dose, longdose, long--term antibiotics toterm antibiotics toprevent relapses or reinfectionsprevent relapses or reinfections

Explain rationale to enhance complianceExplain rationale to enhance compliance


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HemolyticHemolytic--UremicUremicSyndromeSyndrome

PathophysiologyPathophysiology

Diagnostic evaluationDiagnostic evaluation

TherapeuticTherapeuticmanagementmanagement

PrognosisPrognosis

Nursing considerationNursing consideration


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Wilms TumorWilms Tumor

EtiologyEtiology


Therapeutic managementTherapeutic management Surgical removalSurgical removal

Chemotherapy and/orChemotherapy and/orradiationradiation

Nursing considerationsNursing considerations


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Renal FailureRenal Failure

Acute renal failure (ARF)Acute renal failure (ARF)

Chronic renal failureChronic renal failure

(CRF)(CRF)


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Acute Renal Failure (ARF)Acute Renal Failure (ARF)

Definition: kidneys suddenly unableDefinition: kidneys suddenly unableto regulate volume and compositionto regulate volume and compositionof urineof urine

Not common in childrenNot common in children

Principal feature is oliguriaPrincipal feature is oliguria

Associated with azotemia, metabolicAssociated with azotemia, metabolicacidosis, and electrolyte disturbancesacidosis, and electrolyte disturbances

Most common pathologic cause:Most common pathologic cause:transient renal failure resulting fromtransient renal failure resulting from

severe dehydrationsevere dehydration


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Acute Renal Failure (ARF)Acute Renal Failure (ARF)

PathophysiologyPathophysiologyusuallyusuallyreversiblereversible

Diagnostic evaluationDiagnostic evaluation Therapeutic managementTherapeutic management



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Complications of ARFComplications of ARF

HyperkalemiaHyperkalemia

HypertensionHypertension

AnemiaAnemia SeizuresSeizures

HypervolemiaHypervolemia

Cardiac failure with pulmonaryCardiac failure with pulmonaryedemaedema


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Chronic Renal Failure (CRF)Chronic Renal Failure (CRF)

Begins when diseased kidneysBegins when diseased kidneyscannot maintain normal chemicalcannot maintain normal chemicalstructure of body fluidsstructure of body fluids

Clinical syndrome calledClinical syndrome called uremiauremia


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Potential Causes of CRFPotential Causes of CRF

Congenital renal and urinaryCongenital renal and urinarytract malformationstract malformations

VUR associated with recurrentVUR associated with recurrentUTIsUTIs

Chronic pyelonephritisChronic pyelonephritis

Chronic glomerulonephritisChronic glomerulonephritis


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CRF (contd)CRF (contd)

PathophysiologyPathophysiology


Therapeutic managementTherapeutic management Manage diet, hypertension,Manage diet, hypertension,

recurrent infections, seizuresrecurrent infections, seizures



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DialysisDialysis

PeritonealPeritonealdialysisdialysis

HemodialysisHemodialysis

HemofiltrationHemofiltration


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Peritoneal DialysisPeritoneal Dialysis

The preferred method of dialysis forThe preferred method of dialysis forchildrenchildren

Abdominal cavity acts asAbdominal cavity acts as

semipermeable membrane forsemipermeable membrane forfiltrationfiltration

Can be managed at home in someCan be managed at home in somecasescases

Warmed solution enters peritonealWarmed solution enters peritonealcavity by gravity, remains for period ofcavity by gravity, remains for period oftime before removaltime before removal


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HemodialysisHemodialysis

Requires creation of a vascularRequires creation of a vascularaccess and special dialysisaccess and special dialysisequipmentequipment

Best suited for children who can beBest suited for children who can bebrought to facility 3 times/weekbrought to facility 3 times/weekfor 4 to 6 hoursfor 4 to 6 hours

Achieves rapid correction of fluidAchieves rapid correction of fluidand electrolyte abnormalitiesand electrolyte abnormalities


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TransplantationTransplantation

From living related donorFrom living related donor

From cadaver donorFrom cadaver donor

Primary goal is LT survival ofPrimary goal is LT survival of

grafted tissuegrafted tissue

Role of immunosuppressant therapyRole of immunosuppressant therapy

genitourinary dysfunction

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